In general, 95% of commenters agreed that CMS should pivot the concept of meaningful use functional requirements into pay for performance rewards for achieving outcomes via MACRA.

Several commenters pointed out that the MU program has different approaches for Medicaid providers and Medicare providers. Medicaid funding is available to help providers purchase technology. Medicare providers received stimulus in the past and now are entering the penalty phase for not attesting to meaningful use. I did not mean to suggest that Medicaid funding should cease before EHRs are fully deployed in Medicaid provider locations. My suggestions referred to the Medicare programs and penalties for not implementing prescriptive functional requirements.

I was asked to clarify my thoughts about certification. Today's certification program includes onerous requirements that consume vast amounts of resources for items not related to interoperability. If we focus on three goals (provider to provider push, provider to provider pull, and patient pull), then a streamlined certification program validating those three functions would make sense. Just as a DVD player includes a sticker guaranteeing "Blu-Ray" compliance, I can imagine a streamlined certification program that issues "stickers" for each of the three interoperability goals, reassuring clinicians that the health information exchange claimed is fully functional in the products they buy.

I was asked if I was criticizing CMS or ONC work. I'm really not criticizing anyone. I'm suggesting that the work done in the past was foundational, but the future requires a different approach: outcomes based incentives. I'm confident that CMS and ONC staff can evolve existing programs into this new approach.

Finally, some have advocated for a transitional approach along the road to FHIR, since existing standards such as IHE XDS/XUA are already in the marketplace. I realize that we cannot go from cars to jet planes without a few intermediate steps. However, we have to proceed very carefully because for vendors, every OR becomes an AND. If we say that you could use IHE XDS or FHIR, we will run into impedance mismatches. Not only will vendors have to implement every option, they will have to implement step up/step down conversions between organizations that use different options. In general, optionality is the greatest impediment to interoperability. If the entertainment industry decided that laser disc and Blu-Ray should be used simultaneously, our home systems would become very complex and hard to maintain. While I understand that some optionality could be offered during a transition period, I am advocating for a move to FHIR/OAuth as the ONLY approach, with minimal optionality, as quickly as is practical.

I look forward to the continued comments. Let's keep the dialog going!